As a general rule, maternity needs are shareable and are treated like any other medical need.
Pregnancy is considered a pre-existing condition if conception occurs within the first 60 days of the membership. Zion Health requires notes from the first provider visit in order to verify the conception date.
As with any other medical need, expectant mothers pay a single IUA for all expenses related to their maternity need. Shareable expenses may be related to miscarriage, prenatal care, postnatal care, and delivery. STD screenings prescribed by a licensed practitioner as part of routine prenatal care are shareable as part of the maternity need. Maternity need requests must be submitted within 30 days from the date the member’s pregnancy is verified.
Any need of the baby, whether occurring before or after birth, including congenital conditions, is separate from the mother’s maternity need. Expenses for any pregnancy or birth-related complications of the mother will be shared as part of the maternity need.
Early Sharing Request
A maternity care provider may reduce normal charges if a member prepays some or all of the bill. If this is the case, Zion Health will consider sharing the maternity need prior to delivery. To be considered for early sharing, the member must submit an estimate from the provider with the need request form.
Like any other shareable medical expense, the IUA must be paid prior to any cost sharing. The IUA must be paid within six months of the first date of service or the maternity need may become ineligible for sharing. Consideration will be given for situations where the cost of treatment has not exceeded the IUA after six months. Please contact Maternity Needs in this situation. Any late payment fees or interest charges incurred because of a late IUA payment are not shareable.
Home births typically incur fewer expenses. If the costs are significantly lower for a home birth than for a hospital birth and the member is under the care of a licensed care provider, Zion Health may partially waive the IUA for the maternity need.
The baby’s needs are fully shareable, even if the baby is born prematurely. Any services not included in a standard maternity need would be considered a separate need of the baby.
Routine care for a newborn without complications is included with an eligible maternity need.
NICU care and other complications are treated as a separate need of the baby. Expenses related to circumcision are excluded from sharing.
Pregnancy Prior To Membership
Conception that occurs prior to membership or within the first 60 days of membership is not shareable.
For any pregnancy that is not shared as an eligible maternity need with Zion Health, any newborn complications or medical conditions present at the time of birth are considered preexisting and are subject to the applicable waiting periods for sharing.
Expenses related to a surrogate pregnancy, whether or not the surrogate is a member, are not shareable.
Expenses related to fertility treatments are not shareable.